Slow action on nursing home problems

Published 2:01 pm, Tuesday, February 16, 2010

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Mary Koenig wipes away tears as she remembers her father, retired construction worker Emilio Gonzalez, who died at age 76 in 2007 after suffering severe bedsores. He had been staying at Retama Manor Nursing Center in San Antonio. less

Mary Koenig wipes away tears as she remembers her father, retired construction worker Emilio Gonzalez, who died at age 76 in 2007 after suffering severe bedsores. He had been staying at Retama Manor Nursing ... more

Slow action on nursing home problems

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Editor's note: This story originally appeared Sunday, Feb. 14, exclusively in the print edition of the San Antonio Express-News.

By the time Emilio Gonzalez left Retama Manor Nursing Center in August 2007, the 76-year-old retired construction worker had wasted away from 132 to 109 pounds. He was dehydrated, feverish with pneumonia and suffering from two gaping bedsores on his buttocks that had blackened his flesh and rotted his tissue to the bone.

?He must have been in so much pain,? said Gonzalez's daughter, Mary Koenig, who filed a complaint against the nursing home in September 2007. ?He was still entitled to a little dignity, a little respect.?

But like many complaints against nursing homes, state investigators arrived late ? weeks after the deadline imposed under state rules ? and found the nursing home was not at fault.

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The case was among more than 2,200 claims of abuse, neglect and bad medical care against San Antonio's 55 licensed nursing homes between 2006 and 2009.

Interviews with families and advocates and a review of thousands of pages of public records by the San Antonio Express-News show some of the city's most frail and vulnerable residents are suffering at the hands of their caregivers. Yet state officials allow troubled nursing homes to continue operating with little or no penalty.

The lack of oversight comes at a human cost. Elderly residents were left for hours in their own urine and feces. Infestations of cockroaches and rats plagued some facilities. Employees yelled insults at residents and handled them roughly. Nursing home staff stole medication and administered the wrong drugs to residents. State inspectors found dirty feeding tubes and broken medical equipment.

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The state received nearly 16,200 reports of poor treatment last year in Texas, but most ? about four out of five ? were unsubstantiated by investigators, who often arrive at the nursing home weeks after receiving the complaint.

To be sure, many of the city's nursing homes consistently receive high marks from regulators and usually provide safe, clean conditions for residents. But some homes repeatedly failed to provide safe conditions and adequate medical care.

To assess the quality of the city's nursing homes, the Express-News reviewed ratings provided by the state and federal governments. Based on regular health and safety inspections by state regulators, the ratings, though imperfect, show how well homes comply with standards for staffing, health care, cleanliness and other factors.

Reporters also visited 10 of the city's nursing homes ? ranging from the top to the lowest rated ? and interviewed workers, administrators and residents.

With the ratings as a guide, the newspaper examined more than 3,000 pages of abuse and neglect investigations and annual inspections of 10 nursing homes with the lowest scores. It also reviewed dozens of wrongful-death lawsuits filed against local nursing homes to examine how Texas watches over its elderly.

When investigators do cite facilities for serious problems, nursing home operators rarely face sanctions. In some cases, the state repeatedly threatened to suspend or revoke the licenses of facilities with chronic problems, yet Texas rarely took action against those nursing homes. Often, a facility promises to do better, state regulators back off, and problems crop up again in a troubling cycle.

DADS also is failing to enforce a state law that requires nursing homes to report details about every resident who dies. State officials are supposed to analyze the fatality reports to publicize problems and trends, but that research isn't being done.

?Our hands seemed to be tied. It's almost impossible to get a license revoked,? said Kennedy, who was appointed by both George W. Bush and Rick Perry. ?I felt our recommendations meant nothing.?

A spokeswoman for DADS, Cecilia Fedorov, acknowledged the state struggles to respond quickly to the thousands of complaints filed every year against nursing homes. Many of the 316 investigators who monitor the state's 1,196 nursing homes are medical professionals in high demand. One in four left the job during the agency's most recent fiscal year.

?We do face challenges and we have concerns about the timeliness of investigations,? Fedorov said.

Fedorov emphasized the state conducts detailed annual inspections, which are unannounced, and in 2007 DADS took the unusual step of closing a nursing home in San Antonio, Mayfield Care Center. She promised DADS would start collecting fatality reports.

On Friday, DADS announced it plans to add 35 investigators and create special teams to improve response times.

?While we're doing a good job responding to the most serious complaints and incidents, I'm concerned about our ability to respond quickly to every complaint and incident,? DADS Commissioner Chris Traylor said in a written statement. ?We need to do all we can to ensure the safety of Texans in nursing homes.?

Cases like Emilio Gonzalez's, which included measurements and photos of his bedsores taken at the hospital, raise questions about the reliability of state oversight.

After Gonzalez's daughter reported his case, the complaint languished for two months before a state investigator visited Retama Manor West on Cupples Road.

By then, it was too late. Gonzalez, who also was afflicted with Parkinson's disease, died a week before investigators asked any questions about his case.

Slow state response

The delay in Gonzalez's case wasn't isolated. When nursing home residents were possibly harmed by their caregivers last year, state investigators failed to quickly respond to two out of three cases within a required 10 working-day deadline, according to data from the Centers for Medicare and Medicaid Services, or CMS.

Experts said the delays pose risks for residents who may need help, and make it difficult for inspectors to root out the cause of the problem.

?What this primarily comes down to is a resource issue,? said David Wright, the CMS branch chief for Texas . ?You've got a finite number of people who are tasked with performing an increased workload.?

Wright said the shortage of inspectors stems from a ?flat-line? budget for hiring state inspectors, known as surveyors, whose numbers have remained stagnant.

Meanwhile, serious complaints against nursing homes have increased in Texas . Complaints about problems that put residents in ?immediate jeopardy,? the most serious type of complaint, rose 26 percent since 2006, to more than 950. Complaints of ?actual harm,? the second most urgent type of complaint, rose by 10 percent since 2006, to nearly 6,300.

Wright stressed that investigators, who in nearly all cases reach the immediate jeopardy complaints within the required two-day deadline, have rightly focused their efforts on the most crucial cases of immediate jeopardy. Texas lags in responding quickly to all other complaints.

?They're obviously doing the best they can with the resources they have,? Wright said.

The two-month delay in Gonzalez's case illustrates a common complaint about how Texas investigates neglect and abuse.

?By the time the regulatory person has gotten to the nursing home, (staff members) have cleared it up or moved it around,? said Beth Ferris with Texas Advocates For Nursing Home Residents. ?They've done something so the investigator can't find the problem. And if they can't see the problem, they can't substantiate.?

In Gonzalez's case, the state investigator reviewed the nursing home's records, which showed he had two small bedsores ? which are open sores that can decay if left untreated. The medical records at the nursing home showed the sores were healing, and no penalty was issued.

But the state inspector failed to note the nursing home's medical records were incomplete. The bedsore measurements stopped Aug. 6 ? two weeks before Gonzalez went to the hospital on Aug. 20, according to documents turned over as part of a lawsuit filed by his family.

When Gonzalez arrived at Southwest General Hospital , his bedsores had worsened. The sores measured twice the size of what the nursing home had last documented. The hospital also determined Gonzalez was malnourished.

Although federal rules allow surveyors to cite nursing homes that don't check bedsores on at least a weekly basis, the inspector didn't issue a violation.

Like many of the two dozen families that filed wrongful death lawsuits against local nursing homes since 2007, Gonzalez's family blames a pattern of neglect for his death.

Retama Manor West, which offers 139 beds in a dilapidated, orange-colored building, received two out of a possible five-star Medicare rating, a score defined as below average. The home received its lowest marks, one star, in the category for staffing levels, which shows residents received a daily average of 20 minutes of attention from a registered nurse, well below the national average of 36 minutes.

During a recent visit to the home, about 20 residents sat in wheelchairs and listened to Tejano music blaring from a radio. At the center of the group, an aide sat at a desk, absorbed in paperwork, while residents in a nearby room clustered around a TV. The nursing home was rundown but clean and free of bad odors.

A spokeswoman for Retama Manor West, Nan Impink, defended the track record of the nursing home, which has faced three wrongful death lawsuits since 2008.

?That facility works diligently and has had pretty good outcomes over the years, and unfortunately sometimes things happen,? she said.

Sex assault unpunished

Even when state surveyors make their deadlines, they still find a lack of evidence to confirm complaints.

?Surveyors aren't CSI investigators,? said a DADS employee who's knowledgeable about the survey process and requested anonymity because she didn't have permission to speak to the media. ?They have to rely on interviews or record review to prove up a case. If you can't get anyone willing to talk to you, you have to rely on what's in the record, or what you observe.?

The outcome of an inquiry depends on whether a nursing home violated a regulation ? not whether a resident was harmed.

In the case of Martha Starrett, an 82-year-old resident at Parklane West Healthcare Center, staff members told police that a male resident walked into her room late at night in May 2007.

One worker said she peeked into the room and saw the man naked on top of Starrett, who also was naked and suffered from severe dementia, according to a police report.

At first, the worker assumed the two were married. After a few minutes, she relayed the incident to another staff member, who said the man didn't belong in Starrett's room. Workers whisked him back to his own room and called police. But Starrett was unable to recall what happened, and the man told a detective that Starrett had invited him to her room and he was not charged.

A DADS investigator who looked at the case didn't focus on whether the sexual assault occurred, state records show. Instead, the surveyor noted the number of workers at the facility that night who met state requirements. The complaint was unsubstantiated, and the nursing home faced no penalties.

Parklane West spokesman Matt Fontana said the nursing home reported the incident and removed the man from the home. He emphasized that investigators cleared the nursing home of any fault.

At Heartland of San Antonio on the Northeast Side, the state received six reports between October 2006 and May 2008 that bedsores and wounds went untreated and patients were left in bed without being turned. A year after the pattern of complaints emerged, former resident Dorothy Dunston, 67, died after developing an infected bedsore over her tailbone.

?Somebody needs to stand up for her and everyone else,? said her daughter, Linda Dunston-Reese, who sued the nursing home. ?It's like they don't have anybody they have to answer to.?

The Texas attorney general's office posts a warning on its Web site about the shortcomings of state investigations and advises consumers to disregard the high number of unsubstantiated complaints against nursing homes.

?Keep in mind that, although a problem may have existed at the time a complaint was filed, when DADS arrives at the facility, the problem may not still exist, or there may no longer be any evidence. For this reason, pay attention not only to the complaints that are ?substantiated,' but to the total number of complaints.?

Repeat violations

Not every complaint goes unsubstantiated. State surveyors verify one out of five complaints, and also spot violations when they perform unannounced inspections.

At Southeast Nursing and Rehabilitation Center on Southcross Boulevard , an inspection team in 2007 found the nursing home was failing to adequately treat residents suffering from bedsores ? including one resident whose wound had decayed to the bone. The resident was positioned in a Kinetic Concepts wound-treatment bed, but it was making ?burping noises? and its settings were fluctuating. A nursing home worker had no idea how to fix the settings.

After the failed inspection in 2007, the nursing home promised to correct its problems and it remained open.

Linda Young, the administrator for the nursing home, said she couldn't comment on past infractions but said: ?The quality of care is excellent.?

In another case in July 2007, Mary Curry, a resident at Trisun Care Center on Wurzbach Road , wheeled herself past the front desk and out the front door, unnoticed by staff. Outside, she rolled down a steep grade, her wheelchair struck a curb and she flew out of the chair. Curry bashed her head on the sidewalk and broke her leg. Investigators said the home failed to keep safe watch over her.

Trisun said in a written statement that it regretted the accident, but is confident it followed state rules.

Some nursing homes violate the same rules time after time.

At San Pedro Manor, state surveyors cited the facility Oct. 14 for failing to properly treat and prevent bedsores. The nursing home said it corrected the problem, but two months later officials cited the home again for bedsore problems.

Vincent DiMaio, a retired Bexar County medical examiner who has testified as an expert witness in nursing home lawsuits, said that even when investigators discover bad care in a nursing home, the problems often continue.

?What happens is the nursing home says we promise to make all the corrections, we changed our policies. Everyone promises to be better,? DiMaio said.

Whistleblower silenced

It's impossible for the state to do its job without cooperation from nursing home workers. But at least five employees claim in lawsuits they were fired since 2006 after trying to raise concerns with their employers and state regulators about problems at local nursing homes.

In one case at Salado Creek Living and Rehabilitation Center, a former physical therapist, Barbara Freeman, contends she was fired for raising concerns about Robert Polk, a resident who choked for three hours in January 2009 because she said the nursing home didn't have the proper medical equipment to treat him.

As Polk hacked and heaved in his wheelchair trying to clear phlegm in his airway, staff members debated how to help him. They came up with bizarre strategies.

A worker who witnessed the man choking said staff members talked about stealing the proper equipment from another nursing home, or replacing the missing parts with tubing from Auto Zone. The worker asked not to be named for fear of retaliation.

Eventually, a worker drove to another facility and borrowed a suction machine, which the nurses used to clear the man's breathing. But the workers who witnessed his struggle told Freeman ?they were convinced that had the patient been suctioned much earlier, he would not have died,? according to court documents. Freeman declined through her lawyer to talk about the lawsuit.

The nursing home administrator, Mike Conrad, who took over in December, said he wasn't aware of the case. Since the incident, he stressed that the facility has brought in a new director of nursing and many new workers.

?I can assure you that's just not the way we operate,? Conrad said.

Sandra Polk, the widow, said the facility never informed her about the incident surrounding her husband's death. She said she had dogged the nurses for months about their failure to keep his airway clear. The description of her husband's final struggle, which is laid out in the lawsuit, brought her to tears.

She said a worker told her that he had died in his sleep, and she imagined that he passed away peacefully. But when she first viewed her husband's body at the nursing home, his face was streaked with tears and still moist.